What Leaders Can Learn from Feeling like a “Middle”

In their 2014 report, Advancing the Academic Health System for the Future, the Association of American Medical Colleges (AAMC) laid out a mandate for leaders in academic medicine: “While our core values and purpose as academic medical centers are immutable, all else in academic medicine is changeable — in fact, needs to be changed — to accommodate a changing world. Everything about how we are structured and organized must be in play.” But offering everything up to a change process becomes a daunting prospect, especially in academic institutions known for gradual evolution.

Barry Oshry’s work on levels of organizational structure provides a window into the challenges and opportunities to advance change in academic medicine. In his book, Seeing Systems: Unlocking the Mysteries of Organizational Life, Oshry sketches out four roles in any organizational system — Tops, Middles, Bottoms, and Customers. Tops are those with ultimate accountability for results, who must delegate responsibility and allocate resources. In academic medicine, Tops may be presidents, deans, or senior hospital leadership. Middles hold the roles to whom the Tops delegate, such as chiefs and hospital VPs, and Bottoms are frontline staff. The boundary between Tops and Middles is often fraught: Tops believe that Middles are ineffective at execution while Middles feel pulled between multiple priorities, struggling to deliver when strategic direction from the top feels lacking.

A key element of Oshry’s theory is that all roles sometimes experience being pulled into another role group. The growing need for alliances across the continuum of care can thrust Tops into the Middle role on a regular basis. Understandably, these dynamics can challenge the identity of Tops, making them feel torn, ineffective, and disregarded — more like Middles. While this is a frustrating place for Tops, we see some opportunity in cultivating collaboration within the organization.

In The Moment You Can’t Ignore, a book about leading the 21st century organization, our colleagues, Barry Dornfeld and Mal O’Connor, introduce the concept of “leading leaders.” They argue that individuals’ relationships to their work are increasingly based on interest in personal development versus allegiance to the institution. Therefore, “the challenge for leaders is to keep the workforce interested and committed while putting strategy into action. To do that, leaders need to align and mobilize people so their individual talents and efforts clearly contribute to the organization’s overall performance.” As a Top, the minimum requirements for this approach are an understanding of how specific Middles can contribute and what interests them. But having a clear understanding of what it’s like to be a Middle can only improve one’s effectiveness. As the environment pressures Tops into the middle of power structures and value chains, some are using the experience of feeling pulled in many directions to connect more effectively to Middles.

The key task facing Tops remains: to strike the right balance between delegating responsibility to Middles and retaining Tops’ ability to take the lead — but the volume of high stakes decisions often makes the tension more difficult to manage. Consider these examples from our recent experience:

Know how long to stay in the middle. We recently worked with a new CEO in a health system with promising quality outcomes, dominant market share, and financial strength. However, these strengths seemingly existed despite the feeble governance structures and culture of the senior team, not because of it. The CEO knew she needed more from her Middles but couldn’t assume her predecessor’s style of being involved in every decision.

To enrich her understanding of the experience of her organization’s Middles, the new CEO drew on her years as a Middle in the same health system and her recent experience of feeling pulled by multiple stakeholders in renegotiation with the system’s physician network. This ability to empathize with the Middles’ situation allowed her tap into their energies and leverage their passion and ideas for the system. She called for a reorganization that broke silos and reduced duplication of effort by asking Middles to draw on system resources — Bottoms that reported up through other Middles — for the first time. Knowing that this would be a difficult but necessary shift, she laid out shared goals and gave the Middles a framework for collaborating across departments. Then, displaying a key skill for leading leaders who want to bring their all to work, she “got out of the way.”

This approach not only achieved the desired outcomes, it also signaled a new way of working, by activating collaboration across departments. Engaging the Middles in strategic collaborations also freed her up to address other things that needed her bandwidth.

Know when to stay out front. We recently posed the question to the CEO of an academic medical center, “How do you know when to give someone more rope and when to take the reins?” She noted that often her first instinct is to wait until one of her Middles asks her for guidance. She puts herself out front when the organization is taking on something political, visible, and financially significant, such as forming an alliance with a national brand in tertiary care or acquiring a major surgical practice — but she knows that does not mean she needs to be the only visible leader.

In reflecting on her leadership style, she emphasized that strong relationships with her Middles and trying to fully understand the perspectives they bring are key ingredients to advancing the organization. This perspective aligns well with the observation that leading leaders requires demonstrating alignment between their passions and development goals, and the mission of the organization that they serve.

When a health system is led by a Top who can set strategic direction while taking a Middle’s perspective when needed, strategies become behaviors quickly, individuals see the power of their contribution to the whole, and results are faster, and they last.